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What Progression has there been of Mental Health Services During the COVID-19 Outbreak in China?

Research Paper Title

Progression of Mental Health Services During the COVID-19 Outbreak in China.

Background

The novel coronavirus disease (COVID-19) has been rapidly transmitted in China, Macau, Hong Kong, and other Asian and European counterparts.

This COVID-19 epidemic has aroused increasing attention nationwide.

Patients, health professionals, and the general public are under insurmountable psychological pressure which may lead to various psychological problems, such as anxiety, fear, depression, and insomnia.

Psychological crisis intervention plays a pivotal role in the overall deployment of the disease control.

The National Health Commission of China has summoned a call for emergency psychological crisis intervention and thus, various mental health associations and organisations have established expert teams to compile guidelines and public health educational articles/videos for mental health professionals and the general public alongside with online mental health services.

In addition, mental health professionals and expert groups are stationed in designated isolation hospitals to provide on-site services.

Experts have reached a consensus on the admission of patients with severe mental illness during the COVID-19 outbreak in mental health institutions.

Nevertheless, the rapid transmission of the COVID-19 has emerged to mount a serious challenge to the mental health service in China.

Reference

Wen, Li., Yuan, Yang., Zi-Han, Liu., Yan-Jie, Zhao., Qinge, Zhang., Ling, Zhang., Teris, Cheung. & Yu-Tao, Xiang. (2020) Progression of Mental Health Services During the COVID-19 Outbreak in China. International Journal of Biological Sciences. 16(10), pp.1732-1738. doi: 10.7150/ijbs.45120. eCollection 2020.

Coronavirus: Healthcare Workers & their Mental Health

Research Paper Title

Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019.

Background

Health care workers exposed to coronavirus disease 2019 (COVID-19) could be psychologically stressed.

Objective: To assess the magnitude of mental health outcomes and associated factors among health care workers treating patients exposed to COVID-19 in China.

Methods

This cross-sectional, survey-based, region-stratified study collected demographic data and mental health measurements from 1257 health care workers in 34 hospitals from January 29, 2020, to February 3, 2020, in China. Health care workers in hospitals equipped with fever clinics or wards for patients with COVID-19 were eligible.

The degree of symptoms of depression, anxiety, insomnia, and distress was assessed by the Chinese versions of the 9-item Patient Health Questionnaire, the 7-item Generalized Anxiety Disorder scale, the 7-item Insomnia Severity Index, and the 22-item Impact of Event Scale-Revised, respectively. Multivariable logistic regression analysis was performed to identify factors associated with mental health outcomes.

Results

A total of 1,257 of 1,830 contacted individuals completed the survey, with a participation rate of 68.7%. A total of 813 (64.7%) were aged 26 to 40 years, and 964 (76.7%) were women. Of all participants, 764 (60.8%) were nurses, and 493 (39.2%) were physicians; 760 (60.5%) worked in hospitals in Wuhan, and 522 (41.5%) were frontline health care workers.

A considerable proportion of participants reported symptoms of depression (634 [50.4%]), anxiety (560 [44.6%]), insomnia (427 [34.0%]), and distress (899 [71.5%]).

Nurses, women, frontline health care workers, and those working in Wuhan, China, reported more severe degrees of all measurements of mental health symptoms than other health care workers (eg, median [IQR] Patient Health Questionnaire scores among physicians vs nurses: 4.0 [1.0-7.0] vs 5.0 [2.0-8.0]; P = .007; median [interquartile range {IQR}] Generalized Anxiety Disorder scale scores among men vs women: 2.0 [0-6.0] vs 4.0 [1.0-7.0]; P < .001; median [IQR] Insomnia Severity Index scores among frontline vs second-line workers: 6.0 [2.0-11.0] vs 4.0 [1.0-8.0]; P < .001; median [IQR] Impact of Event Scale-Revised scores among those in Wuhan vs those in Hubei outside Wuhan and those outside Hubei: 21.0 [8.5-34.5] vs 18.0 [6.0-28.0] in Hubei outside Wuhan and 15.0 [4.0-26.0] outside Hubei; P < .001).

Multivariable logistic regression analysis showed participants from outside Hubei province were associated with lower risk of experiencing symptoms of distress compared with those in Wuhan (odds ratio [OR], 0.62; 95% CI, 0.43-0.88; P = .008).

Frontline health care workers engaged in direct diagnosis, treatment, and care of patients with COVID-19 were associated with a higher risk of symptoms of depression (OR, 1.52; 95% CI, 1.11-2.09; P = .01), anxiety (OR, 1.57; 95% CI, 1.22-2.02; P < .001), insomnia (OR, 2.97; 95% CI, 1.92-4.60; P < .001), and distress (OR, 1.60; 95% CI, 1.25-2.04; P < .001).

Conclusions

In this survey of heath care workers in hospitals equipped with fever clinics or wards for patients with COVID-19 in Wuhan and other regions in China, participants reported experiencing psychological burden, especially nurses, women, those in Wuhan, and frontline health care workers directly engaged in the diagnosis, treatment, and care for patients with COVID-19.

Reference

Jianbo, Lai., Simeng, Ma., Ying, Wang., Zhongxiang, Cai., Jianbo, Hu., Ning, Wei., Jiang, Wu., Hui, Du., Tingting, Chen., Ruiting, Li., Huawei, Tan., Lijun, Kang., Lihua, Yao., Manli, Huang., Huafen, Wang., Gaohua, Wang., Zhongchun, Liu. & Shaohua, Hu. (2020) Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Network Open. 3(3):e203976. doi: 10.1001/jamanetworkopen.2020.3976.

Can Internet-Based CBT be used to Treat Young People with OCD?

Research Paper Title

Online Obsessive-Compulsive Disorder Treatment: Preliminary Results of the “OCD? Not Me!” Self-Guided Internet-Based Cognitive Behavioral Therapy Program for Young People.

Background

The development and evaluation of Internet-delivered cognitive behavioral therapy (iCBT) interventions provides a potential solution for current limitations in the acceptability, availability, and accessibility of mental health care for young people with obsessive-compulsive disorder (OCD).

Preliminary results support the effectiveness of therapist-assisted iCBT for young people with OCD; however, no previous studies have examined the effectiveness of completely self-guided iCBT for OCD in young people.

The researches aimed to conduct a preliminary evaluation of the effectiveness of the OCD? Not Me! program for reducing OCD-related psychopathology in young people (12-18 years). This programme is an eight-stage, completely self-guided iCBT treatment for OCD, which is based on exposure and response prevention.

Methods

These data were early and preliminary results of a longer study in which an open trial design is being used to evaluate the effectiveness of the OCD? Not Me!

Participants were required to have at least subc-linical levels of OCD to be offered the online program. Participants with moderate-high suicide/self-harm risk or symptoms of eating disorder or psychosis were not offered the programme. OCD symptoms and severity were measured at pre- and post-test, and at the beginning of each stage of the programme. Data was analysed using generalised linear mixed models.

Results

A total of 334 people were screened for inclusion in the study, with 132 participants aged 12 to 18 years providing data for the final analysis.

Participants showed significant reductions in OCD symptoms (P<.001) and severity (P<.001) between pre- and post-test.

Conclusions

These preliminary results suggest that fully automated iCBT holds promise as a way of increasing access to treatment for young people with OCD; however, further research needs to be conducted to replicate the results and to determine the feasibility of the programme.

Reference

Rees, C.S., Anderson, R.A., Kane, R.T. & Finaly-Jones, A.L. (2016) Online Obsessive-Compulsive Disorder Treatment: Preliminary Results of the “OCD? Not Me!” Self-Guided Internet-Based Cognitive Behavioral Therapy Program for Young People. JMIR Mental Health. 3(3):e29. doi: 10.2196/mental.5363.

Linking Recognition Performance in Participants with Greater PTSD Symptom Severity & Ineffective Encoding Reflected in Altered Modulation of Beta Band Oscillatory Activity

Research Paper Title

Altered Modulation of Beta Band Oscillations During Memory Encoding Is Predictive of Lower Subsequent Recognition Performance in Post-Traumatic Stress Disorder.

Background

The researchers studied the relationship between electrophysiological markers of memory encoding, subsequent recognition performance, and severity of PTSD symptoms in service members with combat exposure (n = 40, age: 41.2 ± 7.2 years) and various levels of PTSD symptom severity assessed using the PTSD Check List for DSM V version (PCL-5).

Methods

Brain activity was recorded using magnetoencephalography during a serial presentation of 86 images of outdoor scenes that were studied by participants for an upcoming recognition test.

In a second session, the original images were shown intermixed with an equal number of novel images while participants performed the recognition task.

Results

Participants recognised 76.0% ± 12.1% of the original images and correctly categorised as novel 89.9% ± 7.0% of the novel images.

A negative correlation was present between PCL-5 scores and discrimination performance (Spearman rs = -0.38, p = 0.016). PCL-5 scores were also negatively correlated with the recognition accuracy for original images (rs = -0.37, p = 0.02).

Increases in theta and gamma power and decreases in alpha and beta power were observed over distributed brain networks during memory encoding.

Higher PCL-5 scores were associated with less suppression of beta band power in bilateral ventral and medial temporal regions and in the left orbitofrontal cortex.

These regions also showed positive correlations between the magnitude of suppression of beta power during encoding and subsequent recognition accuracy.

Conclusions

These findings indicate that the lower recognition performance in participants with greater PTSD symptom severity may be due in part to ineffective encoding reflected in altered modulation of beta band oscillatory activity.

Reference

Popescu, M., Popescu, E-A., DeGraba, T.J. & Hughes, J.D. (2020) Altered Modulation of Beta Band Oscillations During Memory Encoding Is Predictive of Lower Subsequent Recognition Performance in Post-Traumatic Stress Disorder. NeuroImage. Clinical. doi: 10.1016/j.nicl.2019.102154. Epub 2019 Dec 27.

Is ERRT-M Useful and Credible?

Research Paper Title

A Pilot Randomized Controlled Trial of Cognitive Behavioral Treatment for Trauma-Related Nightmares in Active Duty Military Personnel.

Background

The aim of this study was to obtain preliminary data on the efficacy, credibility, and acceptability of Exposure, relaxation, and rescripting therapy for military service members and veterans (ERRT-M) in active duty military personnel with trauma-related nightmares.

Methods

Forty participants were randomised to either 5 sessions of ERRT-M or 5 weeks of minimal contact control (MCC) followed by ERRT-M. Assessments were completed at baseline, post-treatment/post-control, and 1-month follow-up.

Results

Differences between ERRT-M and control were generally medium in size for nightmare frequency (Cohen d = -0.53), nights with nightmares (d = -0.38), nightmare severity (d = -0.60), fear of sleep (d = -0.44), and symptoms of insomnia (d = -0.52), and depression (d = -0.51).

In the 38 participants who received ERRT-M, there were statistically significant, medium-sized decreases in nightmare frequency (d = -0.52), nights with nightmares (d = -0.50), nightmare severity (d = -0.55), fear of sleep (d = -0.48), and symptoms of insomnia (d = -0.59), post-traumatic stress disorder (PTSD) (d = -0.58) and depression (d = -0.59) from baseline to 1-month follow-up.

Participants generally endorsed medium to high ratings of treatment credibility and expectancy.

The treatment dropout rate (17.5%) was comparable to rates observed for similar treatments in civilians.

Conclusions

ERRT-M produced medium effect-size reductions in nightmares and several secondary outcomes including PTSD, depression, and insomnia.

Participants considered ERRT-M to be credible.

An adequately powered randomised clinical trial is needed to confirm findings and to compare ERRT-M to an active treatment control.

Reference

Pruiksma, K.E., Taylor, D.J., Mintz, J., Nicholson, K.L., Rodgers, M., Young-McCaughan, S., Hall-Clark, B.N., Fina, B.A., Dondanville, K.A., Cobos, B., Wardle-Pinkston, S., Litz, B.T., Roache, J.D., Perterson, A.L. & STRONG STAR Consortium. (2020) A Pilot Randomized Controlled Trial of Cognitive Behavioral Treatment for Trauma-Related Nightmares in Active Duty Military Personnel. Journal of Clinical Sleep Medicine. 16(1), pp.29-40. doi: 10.5664/jcsm.8116. Epub 2019 Nov 26.

Does Hardiness Protect Against Alcohol Use in Soldiers?

Research Paper Title

Hardiness Protects Against Problematic Alcohol Use in Male, but Not Female, Soldiers.

Background

Military service members are at high risk for problematic substance use compared with the general population; deployment and combat exposure further increases this risk.

It is thus critical to identify resiliency factors that can buffer the negative effects of military experiences and potentially prevent problematic alcohol use.

The current research examines the extent to which psychological hardiness predicts lower risk of problematic alcohol use and explores potential sex differences in this association.

Methods

Data are from Operation: SAFETY, an ongoing study of US Army Reserve/National Guard soldiers.

Negative binomial regression models examined the relation between baseline hardiness, assessed by the 15-item Dispositional Resiliency Scale, and problematic alcohol use at the 1-year follow-up, assessed by the Alcohol Use Disorders Identification Test (N = 260), controlling for baseline combat exposure (Combat Exposure subscale, Deployment Risk and Resilience Inventory-2) and baseline quantity and frequency of alcohol use.

To examine the impact of hardiness on men and women, models were stratified by sex.

Results

In final, adjusted models, hardiness predicted lower risk of problematic alcohol use (adjusted risk ratio = 0.98; p < .05) for male soldiers and was unrelated to alcohol use for female soldiers (adjusted risk ratio = 1.01; p > .05).

Post hoc analyses explored the impact of each dimension of hardiness (i.e., commitment, control, and challenge) on problematic alcohol use.

Conclusions

Hardiness assessment may complement existing screening tools to identify high-risk populations; interventions to promote hardiness may help in preventing problematic alcohol use, particularly among male soldiers.

Reference

Kulak, J.A., Homish, D.L., Hoopsick, R.A., Fillo, J., Bartone, P.T. & Homish, G.G. (2020) Hardiness Protects Against Problematic Alcohol Use in Male, but Not Female, Soldiers. Psychological Services. doi: 10.1037/ser0000409. Online ahead of print.

Are Alterations in Alpha Synchrony Discriminatory of PTSD?

Research Paper Title

Alterations in Sleep EEG Synchrony in Combat-Exposed Veterans With PTSD.

Background

The researchers assessed whether the synchrony between brain regions, analysed using electroencephalography (EEG) signals recorded during sleep, is altered in subjects with post-traumatic stress disorder (PTSD) and whether the results are reproducible across consecutive nights and sub-populations of the study.

Methods

Seventy-eight combat-exposed veteran men with (n = 31) and without (n = 47) PTSD completed two consecutive laboratory nights of high-density EEG recordings. They computed a measure of synchrony for each EEG channel-pair across three sleep stages [rapid eye movement (REM) and non-REM stages 2 and 3] and six frequency bands.

The researchers examined the median synchrony in nine region-of-interest (ROI) pairs consisting of six bilateral brain regions (left and right frontal, central, and parietal regions) for ten frequency-band and sleep-stage combinations.

To assess reproducibility, they used the first 47 consecutive subjects (18 with PTSD) for initial discovery and the remaining 31 subjects (13 with PTSD) for replication.

Results

In the discovery analysis, five alpha-band synchrony pairs during non-REM sleep were consistently larger in PTSD subjects compared to controls (effect sizes ranging from 0.52 to 1.44) across consecutive nights: two between the left-frontal and left-parietal ROIs, one between the left-central and left-parietal ROIs, and two across central and parietal bilateral ROIs.

These trends were preserved in the replication set.

Conclusions

PTSD subjects showed increased alpha-band synchrony during non-REM sleep in the left fronto-parietal, left centro-parietal, and inter-parietal brain regions.

Importantly, these trends were reproducible across consecutive nights and sub-populations. Thus, these alterations in alpha synchrony may be discriminatory of PTSD.

Reference

Laximinarayan, S., Wang, C., Ramakrishnan, S., Oyama, T., Cashmere, J.D., Germain, A. & Reifman, J. (2020) Alterations in Sleep EEG Synchrony in Combat-Exposed Veterans With PTSD. Sleep. doi: 10.1093/sleep/zsaa006. Online ahead of print.

Identifying Qualitatively Distinct PTSD Symptom Typologies

Research Paper Title

Identifying PTSD Symptom Typologies: A Latent Class Analysis.

Background

Posttraumatic stress disorder (PTSD) is characterised by re-experiencing, avoidance, negative alterations in cognition and mood, and arousal symptoms per the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).

While numerous symptom combinations are possible to meet diagnostic criteria, simplification of this heterogeneity of symptom presentations may have clinical utility.

Methods

In a nationally representative sample of American adults with lifetime DSM-5 PTSD diagnoses from the third wave of the National Epidemiologic Survey on Alcohol and Related Conditions (n = 2,365), the researchers used Latent Class Analysis (LCA) to identify qualitatively distinct PTSD symptom typologies.

Subsequently, they used linear and logistic regressions to identify demographic, trauma-related, and psychiatric characteristics associated with membership in each class.

Results

In contrast to prior LCAs with DSM-IV-TR diagnostic criteria, fit indices for the present analyses of DSM-5 PTSD revealed a four-class solution to the data:

  1. Dysphoric (23.8%);
  2. Threat-Reactivity (26.1%);
  3. High Symptom (33.7%); and
  4. Low Symptom (16.3%).

Exploratory analyses revealed distinctions between classes in socioeconomic impairment, trauma exposure, comorbid diagnoses, and demographic characteristics.

Conclusions

Although the study is limited by its cross-sectional design (preventing analysis of temporal associations or causal pathways between covariates and latent classes), findings may support efforts to develop personalised medicine approaches to PTSD diagnosis and treatment.

Reference

Campbell, S.B., Trachik, B., Goldberg, S. & Simpson, T.L. (2020) Identifying PTSD Symptom Typologies: A Latent Class Analysis. Psychiatry Research. 285:112779. doi: 10.1016/j.psychres.2020.112779. Epub 2020 Jan 23.

Can a Novel Algorithmic Approach Operationalise the Management of Depression & Anxiety for Primary Care?

Research Paper Title

Effects of Brief Depression and Anxiety Management Training on a US Army Division’s Primary Care Providers.

Background

There is a nation-wide gap between the prevalence of mental illness and the availability of psychiatrists. This places reliance on primary care providers (PCPs) to help meet some of these mental health needs.

Similarly, the US Army expects its PCPs to be able to manage common mental illnesses such as anxiety and depression. Therefore, PCPs must be able to close their psychiatric skills gaps via lifelong learning.

Methods

Following needs assessment of PCPs in a US Army division, the curriculum was developed. Objectives targeted pharmacological management of depression and anxiety. Behavioural intervention skills were also taught to treat insomnia.

Didactics and case-based small groups were used. A novel psychotropic decisional tool was developed and provided to learners to assist and influence their future psychiatric practice. Pre-training, immediate post-training, and 6-month assessments were done via survey to evaluate confidence and perceived changes in practice.

The curriculum was executed as a quality improvement project using the Plan, Do, Study, Act framework.

Results

Among 35 learners, immediate confidence in selecting optimal psychotropic and perceived knowledge, skill to change the dose or type of medication, and confidence in prescribing behavioural sleep improved significantly with large effect sizes.

At 6-month follow-up, learners reported that they were more likely to adjust medications for anxiety or depression and were more likely to start a new medication for anxiety or depression because of the training with moderate effect sizes. Use and satisfaction with the psychotropic decisional tool are also reported.

Conclusions

The psychotropic decisional tool illustrates a novel algorithmic approach for operationalising the management of depression and anxiety.

Similar approaches can improve the skills of a variety of PCPs in the management of psychiatric disorders.

Further studies in the military operational setting are needed to assess the effects of similar educational interventions on access to behavioural health care, suicidal behaviours, and unit medical readiness.

Reference

Amin, R. & Thomas, M.A. (2020) Effects of Brief Depression and Anxiety Management Training on a US Army Division’s Primary Care Providers. Military Medicine. doi: 10.1093/milmed/usz443. Online ahead of print.

Let There Be Light (1946)

Introduction

Let There Be Light (1946) – known to the US Army as PMF 5019 – is a documentary film directed by American filmmaker John Huston.

Intended to educate the public about posttraumatic stress disorder and its treatment among returning veterans, the film’s unscripted presentation of mental disability led to Let There Be Light being suppressed by the US government; it was not released until the 1980’s.

It is featured in the docuseries “Five Came Back“.

Outline (Background)

As the US Army was demobilising near the end of World War II it had the task of reintegrating returning military veterans back into peacetime society.

An obstacle veterans faced was the stigma surrounding “shell shock” or “psychoneurosis”, the old terms for posttraumatic stress disorder.

To convince the public, and especially employers, that veterans being treated for battle-induced mental instability were completely normal after psychiatric treatment, on 25 June 1945, the Army Signal Corps tasked Major John Huston with producing the documentary The Returning Psychoneurotics.

Huston visited multiple Army hospitals on the East and West Coasts before deciding upon Mason General Hospital on Brentwood, Long Island. The reasons being that Mason General was the biggest mental health facility on the East Coast, the hospital was located near the Army motion picture production center at Astoria Studio in Queens, New York, and the doctors were very open and receptive to the filming and any psychiatric questions he had.

The new title that Huston gave the film, Let There Be Light, was a reference to Genesis 1:3 of the King James Version of the Bible. This was an allusion to the documentary revealing truths that were previously concealed as too frightening or shameful for acknowledgement.

Outline (Documentary)

The film begins with an introduction, stating that 20% of wartime casualties are of a psychiatric nature.

Veterans are transported from a medical ship to Mason General Hospital to be treated for mental conditions brought about by war.

A group of seventy-five US service members – recent combat veterans suffering from various “nervous conditions” including psychoneurosis, battle neurosis, conversion disorder, amnesia, severe stammering, and anxiety states – arrive at the facility. They are brought into a room and told by an admissions officer to not be alarmed by the cameras, which will make a photographic record of their progress.

Next are scenes of interviews between a doctor and some of the patients about their problems and circumstances leading to that point. Afterwards, various treatment methods are employed to cure them.

Treatments depicted include narcosynthesis, hypnosis, group psychotherapy, music therapy, and work therapy. One soldier who had amnesia was hypnotised to remember the trauma of the Japanese bombings on Okinawa and his life before then. Another is given an intravenous injection of sodium amytal to induce a hypnotic state, curing him of his mental inability to walk.

The treatments are followed by classes (designed to reintegrate patients into civilian life) and group therapy sessions. Therapists make a point of reassuring the patients that there is nothing to be ashamed of for receiving treatment for their mental conditions, and that civilians subjected to the same stresses would develop the same conditions.

At this point the documentary shifts the tone to a sense of normalcy, with the soldiers performing regular activities and complaining about everyday problems.

The film ends with a number of the featured patients participating in a ceremony in which they are discharged, not just from the hospital, but from military service, and returned to civilian life.

Production & Filming Details

  • Narrator(s): Walter Huston.
  • Director(s): John Huston.
  • Producer(s): John Huston and US Army Pictorial Service.
  • Writer(s): John Huston and Charles Kaufman.
  • Music: Dimitri Tiomkin.
  • Cinematography: Stanley Cortez, John Doran, Lloyd Fromm, Joseph Jackman, and George Smith.
  • Editor(s): William H. Reynolds and Genre Fowler Jr.
  • Distributor(s): US Army.
  • Release Date: 1946.
  • Running Time: 58 minutes.
  • Country: US.
  • Language: English.